Manuel da Quinta 23 July 2014 AIDS 2014, Melbourne , Australia

1. Three Country Assessment on Health Screening of Migrant Workers and its Impact on Right to Health and Right to WorkPresentation on the Key Findings and Recommendations Manuel da Quinta 23 July 2014 AIDS 2014, Melbourne , Australia

2. Presentation outline • Assessment scope and methodology • Limitations • Background and rationale • Findings and analysis • Discussion • Recommendations

3. Assessment Scope and Methodology • Focus on the perspectives and experience of sending countries: • Cambodia, Indonesia and the Philippines • Data gathering and analysis using triangulation • Support of in-country NGO partners of CARAM Asia and ILO country offices Assessment findings and recommendations to be used for a planned dialogue between ASEAN and the Arab States in 2014. To develop an understanding of the health screening of migrant workers in ASEAN and its impact on their right to work and right to health throughout the migration cycle.

4. Limitations • Only included documented migrant workers • Mostly focused on land-based migrants • Limited time for field investigation, restricting a comprehensive and detailed analysis of different sectors and all existing programs

5. A case against mandatory health screening of migrants • Violates migrants’ integrity, dignity and private life, especially if performed without the latter's informed consent • Violates right to work • Ineffective public health measure • costly • discriminatory • undermines public health efforts for HIV prevention and treatment • passive and people less likely to be in-charge of their health • can create a false sense of national security • Ineffective determinant of health status and/or ability to perform work • the worker may have a false negative test due to the window period • a negative test speaks little as there can be an exposure after the test itself • having a past or current health condition does not necessarily mean NOT being able to perform work

6. International Labor Standard on HIV and AIDSILO Recommendation 200, 2010 Emphasis on Migrants • Prohibits mandatory testing, screening or disclosure, prohibits discrimination in or exclusion from migration on the basis of real or perceived HIV status • Migrants should have universal access to HIV education, information, treatment, care and support in countries concerned • Provides for training, safety instructions and any necessary guidance to be given in a clear and accessible manner • Ensure a safe and healthy work environment for migrant workers all measures apply to countries of origin, countries of transit and countries of destination Universal access to HIV prevention, treatment, care and support services for all workers working under all forms or arrangements, and at all workplaces, regardless of legal status or occupation

7. Finding 1: Pre-departure medical screening is mandatory, including for HIV Certification: • “Fit to Work” The most significant - if not - the ONLY determining factor, for overseas employment eligibility in all three countries Other Categories of Certification • “Temporarily Unfit” • “Unfit”

9. Finding 1.1: HIV counseling and testing procedures are not informative or confidential “…our recruiting agencies told us that we had to take some medical tests. We were taken in groups to a health center. There they took our blood, urine, checked our eyes, did our x-ray, measured our weight and height. They also checked for head-lice. Then a doctor (lady) took us to a separate room, told us to be naked and checked our breasts, stomach, buttocks for skin disease. We were also told to take out our family planning implants (before going abroad)…they said that because of the heavy work we would have to do in the destination country, we needed to take it out…” a female migrant, Indonesia In the FGDs, referring to the pre-departure medical screening • Only few aware of the medical tests taken • No one received pre-test counseling and limited post-test counseling for positive migrants • No one received their test results personally (Cambodia & Indonesia) • Detailed medical test results including for HIV were disclosed to the recruiting agencies (in all countries)

10. Finding 2: Minimal referral for “unfit to work” migrants Referral from the recruiting agency Cambodia & Indonesia Philippines Medical certification by the testing facilities Test results at designated medical screening facilities Migrants receive results Recruiting agencies Authentication of results and certification at DoH Fit Unfit Unfit Fit Permanent Temporary Training and deployment Permanent Temporary Referred for confirmatory tests and other medical treatment Health service referral Revealed without details and told to get help Treatment , certification and deployment

11. Finding 3: Lost to follow-up a challenge among permanent “unfit to work” migrants • Of est. 800-1000 migrant workers tested every month for GCC countries, approx. 5-10% test “unfit for work” (ASSAADAH, 2013) -- anecdotal • PASEI deploys about 70% of the total OFWs from the Philippines. Among whom, approx. 20% receive “unfit to work” certification on health grounds (PASEI 2013) -- anecdotal • Of the 13,072 Cambodian migrants sent to Thailand between 2012-Oct 2013, 380 (2.9%) “unfit to work” (undisclosed recruiting agency Cambodia) • Limited information available on a seemingly sizeable population • Lack of established mechanisms to follow-up and provide services • NGOs providing limited support including for HIV service referral • Health service delivery model for migrant workers not adequately designed and implemented

12. Unfit Cases by Disease Category by a GAMCA certified clinic in Jakarta

13. Finding 4: Varied deportation processes but most compromise human rights GCC deportations very traumatic and inhumane as reported by migrants • Quarantined and detained if “unfit” on health grounds (4-30 days) • Not allowed contacts, communication or documents • Automatic cancellation of work permit & visa • Very little social or legal support (Philippine OFWs supported by their embassies) • Need employer “exit-visa” • Many handcuffed to the airport

14. Discussion and analysis The need for migrant-sensitive Health Systems Strengthening… • Laws and policies related to migration, and health screening are not harmonized • Low health system capacity to respond to migrants’ health needs • Regulating and monitoring health facilities for quality assurance a challenge • Integrated Health service delivery to meet a broad range of health needs, ensure quality and scale of services provided • Testing and rejecting/deportation VStesting and treating – a missed opportunity

15. 2. Sending countries’ practice on mandatory medical screening including for HIV • Changes must begin at home! • Need clear guidelines and evidence-based service delivery model for medical screening among migrants including for HIV (e.g. VCT or PICT, integrated or stand-alone, etc.) • Must ensure that medical screening practices are evidence informed and human-rights based (i.e. information, counseling, referral for services, etc.) • Must strengthen quality assurance and regulatory mechanism of medical screening facilities • Diplomatic approaches and political interventions needed to address mandatory health screening, related travel restrictions and consequences for employment abroad

16. 3. Host country imposed medical screening guidelines and standards • Health screening guidelines and standards, such as of GAMCA and FOMEMA not specific enough • Lack of scientific to decide “fit to work” or “unfit to work” – need better indicators • “…any spots or marks on one’s chest x-ray is labeled as TB, including marks and scars not even related to TB, from past infections due to pneumonia and so, one is “unfit to work…”GMACA certified medical screening facility in Manila • Guidelines and standards on the testing protocols unclear (such as for provision of information, VCT, service , referral services, etc.) • Clinics do not follow national protocols and guidelines – making it difficult to standardize and regulate

17. 4. Enhancing a corporate social responsible among recruiting agencies, a potential opportunity? • Recruiting agencies largely problematic for migrant workers • Turning “enemies” into allies… • Need to build their knowledge and awareness on the human rights of migrant workers and the positive roles they can play for public health and social benefits • Retain information on migrants throughout the migration cycle • Potential opportunity to develop tri-partite partnership between CSOs, recruiting agencies and medical screening facilities to provide referral services and follow-up support for health and social services • Better cooperation and coordination among recruiting agencies and government agencies to establish mechanism to report on migrants’ health issues

18. Draft Recommendations • Develop and implement in-country and cross-border mechanisms at national, provincial and community levels to better understand and monitor migrant health concerns for strengthening health service delivery • Ensure outright prohibition of mandatory testing of HIV in sending countries. • Remove existing laws and policies that require or allow testing to be used as a screening tool for employment eligibility • Develop protective laws and policies which facilitate migrant workers’ access to needed health and other services including for redress in case of rights violation • Ensure that testing practices mandatorily comply with international guidelines for health screening, including for HIV testing. As a basic minimum standard, it should: • Protect confidentiality • Strengthen counselling • Link to related services and referrals • Ensure safety & reliability of test Focus on “unfit to work” and deportee migrants

19. Conduct operational research to better understand effective health service delivery for migrant workers, particularly to reach the vulnerable migrant workers including deportees and “unfit to work” migrant workers. • Adopt a strict regulatory practice and strengthen monitoring mechanism to ensure quality assurance and adherence of standards of operation and testing standards and procedures by the medical screening facilities. • Make health awareness, health promotion education including for HIV prevention and treatment and SGBV mandatory for all pre-departure orientation, trainings and briefings during medical screening.

20. Mobilize migrant community and empower them to: • Provide legal counselling and services to migrant workers in their native language concerning work safety and workers’ rights, protection of those rights and job opportunities • Ensure that all migrants, regardless of their migration status and nationality, work in sectors and occupation that meets labour standards, including those related to occupational health and safety • Leverage on testing as an opportunity to provide health information and services for migrant workers with health problems, especially “unfit to work” and “permanently unfit to work” including those deported on health grounds. More specifically: • Establish mechanism to ensure a contact-chain is maintained between medical screening facilities and migrant workers for confidential pre and post-test counselling and service referral • Develop and implement mechanism for information sharing regarding epidemiological data collected by the medical screening and recruitment agencies with relevant government institutions and NGOs. This must be done without disclosing the names and details of the migrant workers

21. Develop and implement a referral mechanism between recruitment agencies and NGOs providing services to direct and refer migrant workers with health problems to needed services • Support NGOs to set up outreach and follow-up mechanisms to ensure access to early treatment and other services for unfit to work migrant workers • Sensitize and train recruitment agencies on migrant workers’ health, safety, and well-being as well as on their rights. Mobilize champion recruitment agencies including those with pre-existing mission of social-corporate responsibilities to facilitate migrant workers’ access to information and services regarding health and well-being. • Review and address the shortfalls of medical screening guidelines imposed by host-countries and develop more scientific and evidence based approaches to interpret the findings of medical screening and decide which migrant workers are fit to work. Sending countries can negotiate the setting up of joint committee to review such guidelines with receiving countries and make the required changes.

22. Receiving countries must stop detention and deportation of migrant workers on health grounds. • Strengthen support mechanisms and referral for responding to migrants’ health and social protection needs within host countries. This includes: • Increase the number of attachés and strengthen the involvement of embassies in dispute settlement in host countries • Make information regarding available services in host countries widely available for prospective and current migrants • Establish online peer-support groups in the host countries for enhancing community resilience and lesson sharing • Increase resource allocation for addressing migrant health issues, including for HIV prevention and treatment, through countries own internal resources as well as by efforts to mobilize donors from varied sectors such as through the GF mechanism for health.

23. Acknowledgement and Appreciation Migrant workers Key informant interviews from relevant dept. of ministries of health and labor/migration Recruiting agencies Achieve Philippines CARAM Cambodia SolidaritasPerempuan (SP) in Indonesia CARAM Asia JUNIMA including the UN regional and country offices of – ILO, UNAIDS and UNDP And all of you present here today!

24. THANK YOU